More than 90 percent of pediatric specialists who diagnose attention deficit hyperactivity disorder (ADHD) in children are not following appropriate clinical guidelines put forward by the American Academy of Pediatrics (AAP), a study finds.

The study, conducted by researchers at the Cohen Children's Medical Center of New York, surveyed 3,000 physicians specializing in neurobehavioral conditions.

The Preschool ADHD Treatment Questionnaire (PATQ) asked physicians about how they treated ADHD. Survey questions asked how often physicians recommended parents receive training in behavioral management and how often they prescribed medication as a first- or second-line treatment, and which drugs they prescribed most often, TIME Healthland reports.

The study showed that more than one in five specialists who diagnose and recommend treatment for ADHD in preschoolers recommend drugs first, either alone or accompanied by behavioral therapy.

The AAP recommends behavioral therapy first for preschoolers with ADHD, followed by medication only when behavioral therapy fails.

"It is unclear why so many physicians who specialize in the management of ADHD — child neurologists, psychiatrists and developmental pediatricians — fail to comply with recently published treatment guidelines," said the study's lead author Dr. Andrew Adesman, the chief of developmental and behavioral pediatrics at Cohen Children's Medical Center.

The treatment guidelines Adesman referred to were published when the AAP revised its guidelines for ADHD diagnosis and treatment in 2011.

"Those guidelines were important in that they extended down from age 6 down to age 4. For the first time pediatricians were given guidance in how to approach the management of ADHD in preschoolers," said Dr. Adesman.

The published guidelines established that younger kids could be diagnosed with ADHD, along with advice for how to treat the youngest patients.

Pediatricians are generally uncomfortable with diagnosing ADHD in young children, and refer those patients to specialists, TIME Healthland reports.

"When we undertook this study, we were interested in seeing what the specialists in the field were doing, since pediatricians turned to them and parents turned to them," said Dr. Adesman. "Actually, the AAP in their guidelines specifically state that if a pediatrician is not comfortable with evaluating children — especially young children — for ADHD, then they should turn to these medical specialists."

Those medical specialists include child neurologists, child psychiatrists, and developmental behavior pediatricians.

For situations where ADHD medication is appropriate, the AAP recommends that pediatricians prescribe methylphenidate (Ritalin). However, the study found that more than one in three specialists reported they "often" or "very often" prescribe a different drug first.

Why do physicians prescribe drugs to children diagnosed with ADHD, rather than behavioral therapy, as per AAP recommendation?

The study's authors say that one reason is that behavior management strategies are not always accessible for families, and furthermore may be prohibitively expensive.

However, the study results suggest that the availability of behavior therapy had no bearing on physicians' decisions to prescribe medication as a first-line treatment.

"So as much as I would like to think that doctors are prescribing medicine first line because behavior therapy is not available, that does not seem to be the case," Dr. Adesman said.

Additional reasons doctors medicate rather than recommend behavioral therapy include the long-term commitment of behavior therapy, which can be difficult for busy parents. Furthermore, some studies suggest that for school-age children, medication may be more effective than behavioral therapy.

For Dr. Adesman, these reasons are not enough to justify prescribing ADHD medication to preschoolers.

"There is an important distinction, and that is that even if medication has been shown to be more effective in the short-term than behavior therapy in school age children, medication does not work quite as well or consistently in preschool kids. So a head to head comparison in school age children may not necessarily be appropriate to extrapolate down to the preschool kids," Dr. Adesman said.

"Certainly it would seem that pediatricians and specialists should increasingly look to behavioral interventions as a first line treatment," said Dr. Adesman. "I think parents also should seek at behavioral treatments as first-line, and in general, medication should be reserved for cases where either behavioral therapy is not effective or where it is not available."

The study was presented at the Pediatric Academic Societies in Washington, D.C.